Antipsychotic Pharmacotherapy

Nicole Romstadt, PharmD

Psychiatric Clinical Pharmacy Specialist
Assistant Professor of Pharmacy Practice
Bernard J. Dunn School of Pharmacy
Learning Objectives

• Describe the mechanisms of action for first and second generation

antipsychotics. Then, explain how activity at these receptors contributes to
both desirable and undesirable antipsychotic effects.
• Discuss the common and serious adverse effects associated with first and
second generation antipsychotics.
• Describe the role of long-acting injectable antipsychotics in the treatment of
schizophrenia and related disorders.
• Identify monitoring parameters and adverse effects associated with the use
of clozapine.
Common Antipsychotic Target Symptoms

Positive Symptoms Mania Symptoms

• Delusions • Grossly elevated mood
• Hallucinations • Increased energy/decreased sleep
• Auditory, visual, tactile • Racing thoughts
• Disorganized thinking • Grandiosity
• Irritability/agitation
• Example: Schizophrenia, • Impulsivity/risky behaviors
schizoaffective disorder, etc.
• Example: Bipolar disorder
Common Off-Label Uses

Potentially Inappropriate Indications

• Avoid routine use for these indications:
• Insomnia
• Anxiety disorders
• Post-traumatic stress disorder
• Behavioral and psychological symptoms of dementia
• Delirium
• Acute agitation
• If used, must frequently review the appropriateness, safety and need for
continuation
Brief Review of Pathophysiology

Schizophrenia Spectrum and Other Psychotic Disorders

• Exact mechanism is unknown
• Dopamine (DA) hypothesis
• Most recognized theory
• DA hyperfunction in limbic system leads to positive symptoms
• DA hypofunction in prefrontal cortex leads to negative symptoms
• Other implicated neurotransmitters
• Serotonin, glutamate, GABA, acetylcholine
Antipsychotic Mechanism of Action

Class Commonality
• Dopamine antagonism
• Prevents dopamine from acting
at post-synaptic D2 receptors
• Action in mesolimbic pathway
treats positive symptoms
• Requires approximately
60-70% dopamine blockade
• Higher blockade increases risk
for adverse effects
Dopamine Pathways
Dopamine Pathways

Mesolimbic pathway Nigrostriatal pathway

• Controls movement
• Emotional center related to arousal,
• D2-antagonism leads to extrapyramidal
memory, motivation, reward symptoms (EPS)
• Excess DA contributes to psychosis
• D2-antagonism relieves positive Mesocortical pathway
symptoms • Controls cognition, communication,
executive functioning
Tuberoinfundibular pathway • Decreased DA levels contributes to
negative symptoms
• Innervates pituitary gland • D2-antagonism may worsen negative
• D2-antagonism leads to elevated symptoms
prolactin
Mechanism of Action

Class Variability
• Other receptor involvement
• 5HT2A antagonism is the commonality with SGAs
• May also act as antagonists at ⍺1, H1, M1
• Receptor affinity and activity varies between agents
• May account for either desirable or adverse effects

Miyamoto S et al. Molecular Psychiatry. 2012;17:1206-1227.

Mechanism of Action – Key Receptors

Receptor Mechanism Clinical Effects

D2 Antagonist • Decrease in positive symptoms, mania
• EPS, hyperprolactinemia, cognitive impairment
5HT2A Antagonist • Antidepressant, improvement in negative symptoms
• Reduced EPS
⍺1 Antagonist • Decrease in adrenergic outflow (hyperarousal)
• Orthostasis, reflex tachycardia
H1 Antagonist • Sedation, confusion, falls, weight gain
M1 Antagonist • Decrease in EPS
• Anticholinergic effects (dry eyes, mouth, constipation,
confusion, falls, urinary retention, delirium, etc.)
Miyamoto S et al. Molecular Psychiatry. 2012;17:1206-1227.
Pharmacotherapy Overview

Considerations when selecting medications

• Goals of treatment
• Barriers to adherence
• Consequences of non-adherence
• Individual medication properties
• Adverse effect profiles
• Cost and availability
Goals of Treatment

Phase 1 - Acute Stabilization Phase 3- Maintenance and Relapse

• Reduce threat to self and others Prevention
• Reduce acute psychotic symptoms • Achieve symptom control and
• Improve functioning remission
• Improve social and occupational
Phase 2- Stabilization functioning
• Reduce remaining positive, negative • Continue to promote adherence
and cognitive symptoms and address potential barriers to
• Promote adherence adherence
• Minimize and treat adverse effects
Practice Guidelines for the Treatment of Patients With Schizophrenia. American Psychiatric Association, 2004.
Barriers to Adherence

Patient Factors Environmental Factors

• Medication beliefs and biases • Social stigma
• Education regarding mental • Unstable living environment
illness and medication role • Complex healthcare system
• Lack of perceived efficacy • Medication cost and availability
• Intolerable side effects
• Severe symptoms,
disorganization, poor insight
• Forgetfulness
Consequences of Non-Adherence

• Suboptimal response to treatment

• Functional decline and increased risk for relapse
• Develop treatment resistance
• Kindling effect
• Increased hospitalizations and healthcare burden
• Polypharmacy and complex medication regimens
Schizophrenia Treatment Algorithm

DiPiro JT et al. Pharmacotherapy: A Pathophysiologic Approach, 9e; 2014

Schizophrenia Treatment Algorithm

DiPiro JT et al. Pharmacotherapy: A Pathophysiologic Approach, 9e; 2014

First Generation Antipsychotics
First Generation – “Typical”
• Chlorpromazine (Thorazine®)
• Fluphenazine (Prolixin®)
• Haloperidol (Haldol®)
• Loxapine (Loxitane®)
• Perphenazine (Trilafon®)
• Thioridazine (Mellaril®)
• Thiothixene (Navane®)
• Trifluoperazine (Stelazine®)
Class Characteristics
• Increased incidence of EPS
• More potent D2 antagonism
• Lower incidence of metabolic ADEs
• May worsen negative symptoms
• Result of D2 antagonism in
mesocortical pathway
• Lack of 5HT2A antagonism
FGA D2 Potency Comparison

Low Potency Mild Potency High Potency

Chlorpromazine Loxapine Haloperidol
Thioridazine Perphenazine Fluphenazine
Thiothixene
Trifluoperazine

• Higher doses needed • Lower doses needed for

for antipsychotic effect antipsychotic effect
• Higher incidence of • Higher incidence of
anticholinergic effects, movement-related side
sedation, orthostasis effects
FGA Dosing
Medication Average Typical Max. Daily Special Considerations
Daily Dose Dosing Dose
Chlorpromazine 200-600 mg BID-QID 1000 mg Sedation, anticholinergic, orthostasis
Fluphenazine <20 mg TID-QID 40 mg High incidence EPS
Haloperidol <30 mg BID-TID 100 mg High incidence EPS
Loxapine 20-100 mg BID-QID 250 mg
Perphenazine 8-64 mg BID-QID 64 mg
Thioridazine 50-800 mg BID-QID 800 mg BBW for QTc prolongation
Thiothixene 20-30 mg BID-TID 60 mg
Trifluoperazine 15-20 mg BID 40 mg CI in liver disease
FGA Dosing Considerations

Initiation
• Initiate at low dose and titrate slowly
• Doses are often given 2-4 times per day to improve tolerability
• Less frequent dosing can be trialed once patient is tolerating
• Treatment-naïve patients are at increased risk for adverse effects/EPS

Discontinuation
• Taper over weeks to months to reduce risk for withdrawal and relapse
Black Box Warning

All Antipsychotics
• “Elderly patients with dementia-related psychosis treated with antipsychotic
drugs are at an increased risk of death. [Drug] is not approved for the
treatment of patients with dementia-related psychosis”
Adverse Effects

Extrapyramidal Symptoms (EPS)

• Akathisia
• Dystonia
• Pseudoparkinsonism
• Tardive Dyskinesia
Adverse Effects - EPS

Akathisia
Clinical Presentation • Inability to be still
• Internal restlessness
Mechanism • Unknown
• Related to dopaminergic effects of antipsychotics
Prevention • Initiate at low dose
Management • Discontinue or reduce dose
• Propranolol 30-120 mg/day in divided doses
Adverse Effects - EPS

Acute Dystonic Reaction

Clinical Presentation • Involuntary contraction of skeletal muscle
• Buccal spasms, oculogyric crisis, facial grimacing, trismus
• Onset within days of initiation
Mechanism • Rapid antagonism of D2 receptors in basal ganglia
Prevention • Initiate at low dose
• Prophylactically initiate anticholinergic or antihistamine
• Avoid IM injections
Management • Discontinue or reduce dose
• Benztropine 1-2 mg IM
• Diphenhydramine 25-50 mg
Adverse Effects - EPS

Pseudoparkinsonism
Clinical Presentation • Slowing of voluntary muscle movements (bradykinesia)
• Muscle rigidity (cogwheel)
• Tremor at rest (pill-rolling)
• Shuffling gait, stooped posture
Mechanism • D2-antagonism in nigrostriatal pathway
Prevention • Initiate at low dose
Management • Discontinue or reduce dose
• Benztropine 1-5 mg/day
• Trihexyphenidyl 5-15 mg/day
• Diphenhydramine 25-150 mg/day
Adverse Effects - EPS

Tardive Dyskinesia (TD)

Clinical Presentation • Stereotypical, irreversible involuntary movements
• Includes lip smacking, lateral jaw, tongue movements
• Purposeless movements of neck, trunk and/or extremities
• Later symptom onset; may be months-years after initiation
Mechanism • Possible result of DA hypersensitivity
• Secondary to prolonged D2-antagonism
• Thought to be worsened with prolonged anticholinergic use
Prevention • Minimize antipsychotic exposure
• Attempt periodic gradual dose reductions
• Avoid prolonged anticholinergic use
Adverse Effects - EPS

Tardive Dyskinesia (TD)

Management • Discontinue the suspected antipsychotic
• Consider switching to clozapine
• Attempt to reduce anticholinergic
• Provide supportive treatments
• Valbenazine (Ingrezza®) recently approved by FDA
Monitoring • Abnormal Involuntary Movement Scale (AIMS)
• Every 3-6 months with FGA
• Every 6-12 months with SGA
Adverse Effects

Neuroleptic Malignant Syndrome

Clinical Presentation • Muscle rigidity (Elevated CK)
• Autonomic instability (Elevated HR, BP, Temp)
• Altered mental status
• Onset days to weeks after initiation
Prevention • Use minimum dose of antipsychotic
• Avoid neuroleptic polypharmacy
• Minimize use of IM injections (higher risk)
Management • Discontinue all antipsychotics
• Provide supportive care
• Dopamine agonist – bromocriptine, amantadine
• Skeletal muscle relaxant - dantrolene
Adverse Effects

Cardiovascular
• Clinical presentation
• Orthostatic hypotension (⍺ 1 antagonism)
• Higher incidence with clozapine,
iloperidone, risperidone, quetiapine
• Initiate at low doses, titrate slowly
• QTc interval prolongation
• Torsades de Pointes (TdP)
• Thioridazine has BBW
• Dose-dependent increase
Nielsen J, et al. CNS Drugs. 2011;25:473–490.
Adverse Effects

Cardiovascular
• Monitoring
• ECG at baseline, then annually
• Consider ECG with addition of
QTc-prolonging medications,
dose increases, etc.
• Serum K+, Mg2+ at baseline and
as clinically indicated

Nielsen J, et al. CNS Drugs. 2011;25:473–490.

Adverse Effects

Hyperprolactinemia
• Clinical presentation
• Men: Ejaculatory/erectile dysfunction, galactorrhea, decreased libido
• Women: Amenorrhea, galactorrhea, decreased libido
• Decreased BMD (osteopenia, osteoporosis)
• Increased risk with higher D2 affinity (Includes SGA risperidone)
• Monitoring
• Prolactin level, if clinically indicated
• Not routinely monitored, as prolactin level does not correlate with symptoms
Adverse Effects

Anticholinergic
• Clinical presentation
• Dry mouth, eyes, throat, urinary retention, constipation
• Blurred vision, worsening of glaucoma
• Confusion, delirium, falls (particularly in geriatrics)
Others
• Incidence generally rare and varies between agents
• Transient elevation in LFTs
• Hematologic, Ophthalmologic, Dermatologic reactions
• Lower seizure threshold
FGA Adverse Effect Comparison
Medication Sedation Anticholinergic EPS Hypotension
Chlorpromazine High High Low Moderate
Fluphenazine Low Low Very high Low
Haloperidol Very low Very low Very high Very low
Loxapine Moderate Low Moderate Moderate
Perphenazine Low Low High Low
Thioridazine High High Low High
Thiothixene Low Low High Low
Trifluoperazine Low Low High Low
Second Generation Antipsychotics

Second Generation – “Atypical”

• Aripiprazole (Abilify®) • Paliperidone (Invega®)
• Asenapine (Saphris®) • Quetiapine (Seroquel®)
• Brexpiprazole (Rexulti®) • Risperidone (Risperdal®)
• Cariprazine (Vraylar®) • Ziprasidone (Geodon®)
• Clozapine (Clozaril®)
• Iloperidone (Fanapt®)
• Lurasidone (Latuda®)
• Olanzapine (Zyprexa®)
Second Generation Antipsychotics

Class Characteristics
• Less potent D2 antagonism, shorter duration of receptor occupancy
• Lower incidence of EPS
• 5HT2A antagonism is common mechanism in this class
• Potentially improves negative symptoms (Controversial results)
• Increased incidence of metabolic effects
• Newer agents exhibit D2 partial agonism
• Aripiprazole, brexpiprazole, cariprazine
• Reduces DA neurotransmission, without complete antagonism
• Allows for minimal DA transmission in nigrostriatal, which reduces EPS
SGA Dosing
Medication Average Typical Max. Daily Special Considerations
Daily Dose Dosing Dose
Aripiprazole 20-30 mg Daily 30 mg Partial D2 agonism
Higher incidence of akathisia
BBW for SI in children-adolescents
Asenapine 10-20 mg BID 20 mg Do not eat or drink within 10 mins
Only available as SL
Brexpiprazole 1-4 mg daily 4 mg Partial D2 agonism
BBW for SI in children-adolescents
Cariprazine 1.5-6 mg daily 6 mg Partial D2 agonism

Clozapine 300 – 450 mg daily 900 mg REMS program

Iloperidone 12 – 24 mg BID 24 mg Cardiovascular effects

SGA Dosing
Medication Average Typical Max. Daily Special Considerations
Daily Dose Dosing Dose

Lurasidone 20-120 mg Daily 160 mg Take with 350 calories

BBW for SI in children-adolescents
Olanzapine 10-15 mg Daily 20 mg BBW for post-injection delirium/
sedation syndrome (PDSS) with LAI
Paliperidone 3-6 mg Daily 12 mg Metabolite of risperidone

Quetiapine 400-800 mg Daily-BID 800 mg BBW for SI in children-adolescents

Risperidone 4-6 mg Daily 16 mg Orthostasis, hyperprolactinemia

Ziprasidone 80-160 mg BID 160 mg Take with 500 calories

Adverse Effects

Overlap with FGAs

• Many FGA adverse effects also occur with SGAs
• Overall less EPS and more metabolic adverse effects with SGAs

Metabolic Effects
• Clinical presentation
• Hyperlipidemia
• Weight gain
• Glucose intolerance, DM2
• Hypertension
Adverse Effects

Metabolic Effects
• Monitoring
• Consensus guidelines from the American Diabetes Association, the American
Psychiatric Association, the American Association of Clinical Endocrinologists,
and the North American Association for the Study of Obesity

American Diabetes Association. Diabetes Care. 2004;27(2):596-601.

Adverse Effect Comparison
Medication Sedation Anticholinergic EPS Weight Glucose Lipid
Gain Intolerance Elevation
Aripiprazole Low Low Low Very low Low Very low
Clozapine High High Very low Very high High High
Lurasidone Low Low Low Very low Low Low
Olanzapine Moderate Moderate Low High High High
Paliperidone Low Low High Moderate Moderate Low
Queitapine High Moderate Very low High High High
Risperidone Low Low High Moderate Moderate Low
Ziprasidone Low Low Low Very low Low Very low
Drug Interactions

Pharmacodynamic
• Additive properties of 2+ medications
• Anticholinergic (cognitive impairment, delirium, constipation, etc.)
• Over-sedation (falls, drowsiness)
• QTc prolongation, etc.
Drug Interactions

Pharmacokinetic
• CYP Interactions (both generations)
• APs are primarily metabolized via CYP1A2, 2D6 and 3A4
• Dose reductions may be required with concomitant CYP inhibitors
• May also be required if patient is known poor metabolizer
• Ex. Aripiprazole, brexpiprazole, iloperidone recommend 50% dose
reduction when combined with CYP2D6 and/or 3A4 inhibitors
• Hydrocarbons produced from smoking cigarettes induce CYP1A2
• May reduce levels of clozapine and olanzapine, requiring dose adjustments
if smoking status changes
Antipsychotic Conversion

Oral Conversion Strategies

• Discontinue old medication and initiate the new one (no-overlap)
• Increased risk for withdrawal symptoms
• Cannot be done with clozapine
• Initiate new medication at full dose, then taper off old medication
• Increased risk for adverse effects while on two treatment doses
• Slowly cross taper by initiating new medication at low dose, while decreasing
old medication
• Reduces risk for withdrawal or adverse effect symptoms
• Taper length (usually 1-2 weeks) varies based on treatment location (inpatient
vs. outpatient), patient tolerability and response
Long-Acting Injectable Antipsychotics (LAIs)

Goals of Treatment
• Improve adherence to antipsychotics
• It’s estimated that 40-50% of patients are non-adherent to antipsychotics,
which may lead to negative outcomes, including:
• Functional decline
• Relapse and treatment resistance
• Psychiatric hospitalizations
• Increased healthcare costs
Long-Acting Injectable Antipsychotics (LAIs)

Role in Treatment
• Chronic mental illness in patients with history of relapse following oral
antipsychotic non-adherence
• Particularly if patient manages medications independently
• Typically not first-line in antipsychotic naïve patients
• Oral formulations more easily titrated and less expensive
• Patients preferring injectable agent versus oral agent

Bartolomeis A, et al. Neuropsychiatr Dis Treat. 2016;12:99-108.

Long-Acting Injectable Antipsychotics (LAIs)

Available Agents
• First Generation Antipsychotics
• Fluphenazine decanoate
• Haloperidol decanoate
• Second Generation Antipsychotics
• Risperidone (Risperdal Consta®)
• Paliperidone (Invega Sustenna®, Invega Trinza®)
• Olanzapine (Zyprexa Relprevv®)
• Aripiprazole (Abilify Maintena®, Aristada®)
First Generation LAIs

Medication Dosing Oral Overlap Considerations

Fluphenazine • Starting dose = 1.25x PO • Continue • Deltoid or gluteal
decanoate dose until 2nd LAI IM injection
• Maintenance = 12.5-100 dose • Z-track technique
mg IM every 2-4 weeks

Haloperidol • Starting dose = 10-15x PO • Continue • Deltoid or gluteal

decanoate dose until 2nd LAI IM injection
• 50-200 mg IM every 4 dose • Z-track technique
weeks • Give as two
injections for doses
>100 mg
Second Generation LAIs

Medication Dosing Oral Overlap Considerations

Aripiprazole lauroxil • Starting dose based on oral • 21-day oral • Adjust dose for
(Aristada®) • 441 mg, 662 mg, or 882 mg aripiprazole CYP2D6 and/or 3A4
IM q4-6 weeks interactions
• Deltoid or gluteal
Aripiprazole • Standard dose is 400 mg; • 14-day oral • Adjust dose for
monohydrate dose reduced if DDIs aripiprazole CYP2D6 and/or 3A4
(Abilify Maintena®) • 200 mg, 300 mg, 400 mg or other AP interactions
IM qmonth
• Deltoid or gluteal
Second Generation LAIs

Medication Dosing Oral Overlap Considerations

Olanzapine pamoate • Starting dose based on oral • None • REMS program
(Zyprexa Relprevv®) • 210 mg, 300 mg, 405 mg • Provider, patient
IM q2-4weeks and facility must be
• Gluteal registered

Paliperidone • Loading sequence of • None • Detailed directions

palmitate 234 mg, then 156 mg in package insert
(Invega Sustenna®) • 39 mg, 78 mg, 117 mg, regarding
156 mg, 234 mg IM requirements for
qmonth missed doses
• Deltoid (initial) then either
deltoid or gluteal
Second Generation LAIs

Medication Dosing Oral Overlap Considerations

Paliperidone • Starting dose based on • N/A • Must be stable on
palmitate current Invega Sustenna® monthly LAI
(Invega Trinza®) maintenance dose formulation for at
• 273 mg, 410 mg, 546 mg, least 4 months,
819 mg IM q3months then transition
• Deltoid or gluteal directly to Trinza®
Risperidone • Starting dose 12.5-25 mg • 21-day oral • Microsphere
microspheres • 12.5 mg, 25 mg, 37.5 mg, risperidone release is delayed
(Risperdal Consta®) 50 mg IM q2weeks or other AP 3-weeks post
• Deltoid or gluteal injection
Clozapine (Clozaril®)

Treatment Resistant Schizophrenia

• Lack of significant symptom improvement despite adequate trials (dose, duration,
adherence) of at least two antipsychotics (at least one SGA)

Clozapine
• Guidelines recommend clozapine for “patient who has had no response or partial
and suboptimal response to two trials of antipsychotic medication or for a patient
with persistent suicidal ideation or behavior that has not responded to other
treatments”
• Evidence has consistently shown clozapine to be superior to other antipsychotics in
this patient population

Practice Guidelines for the Treatment of Patients With Schizophrenia. American Psychiatric Association, 2004.
Clozapine (Clozaril®)

Mechanism of Action
• Low potency at D2 receptor and high affinity for 5HT2A
• Very low EPS and may improve TD
• Antagonism at ⍺1, H1 and M1 contributes to significant side effect profile
Receptor Mechanism Clinical Effects
⍺1 Antagonist • Decrease in adrenergic outflow (hyperarousal)
• Orthostasis, reflex tachycardia
H1 Antagonist • Sedation, confusion, falls, weight gain
M1 Antagonist • Decrease in EPS
• Anticholinergic effects (dry eyes, mouth, constipation,
confusion, falls, urinary retention, delirium, etc.)
Miyamoto S et al. Molecular Psychiatry. 2012;17:1206-1227.
Clozapine (Clozaril®)

Black Box Warnings

• Dementia-related mortality
• Severe neutropenia
• Orthostatic hypotension
• Myocarditis
• Seizures

Clozaril® [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2014.
Clozapine (Clozaril®)

Mitigating Severe Adverse Effects

• Dose-related effects
• Neutropenia, orthostatic hypotension, bradycardia, syncope, seizures
• Initiating at low doses and slow titration reduces risk
• Titration
• Initial dose of 12.5 mg 1-2 times per day
• Increase total daily dose (TDD) by 25-50 mg per day, as tolerated
• Goal of 300-450 mg divided 2-3 times per day
• Must restart dose titration if interruption in therapy ≥ 2 days

Clozaril® [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2014.
Clozapine (Clozaril®)

Risk Evaluation and Mitigation Strategy (REMS) Program

• Patient, prescriber and pharmacy must be registered
• Outlines absolute neutrophil count (ANC) monitoring requirements
• Once weekly for first 6 months
• Every-other-week after 6-12 months
• Once monthly after 12 months

Clozapine REMS Program website (www.clozapinerems.com)

Clozapine (Clozaril®)

Clozapine REMS Program website (www.clozapinerems.com)

Clozapine (Clozaril®)

Clozapine REMS Program website (www.clozapinerems.com)

Clozapine (Clozaril®)

Other Adverse Effects

• High incidence of metabolic effects and lowest incidence of EPS
• Constipation
• Consider prophylactic bowel regimen
• Sialorrhea
• May require pharmacotherapy if bothersome to patient
• Sublingual anticholinergic - ipratropium nasal spray or atropine eye drops
• Oral anticholinergic - benztropine or oxybutynin
Cost Considerations
Medication Generic Example Average Wholesale
Dosing Price for 30DS

Chlorpromazine Yes 100 mg BID $892

Fluphenazine Yes 5 mg BID $72

Haloperidol Yes 10 mg BID $107

Cost Considerations
Medication Generic Example Average Wholesale
Dosing Price for 30DS

Aripiprazole Yes 20 mg daily $1362

Asenapine No 10 mg BID $1316

Brexpiprazole No 3 mg daily $1211

Cariprazine No 4.5 mg daily $1316

Clozapine Yes 100 mg BID $205

Iloperidone No 10 mg BID $2364

Cost Considerations
Medication Generic Example Average Wholesale
Dosing Price for 30DS

Lurasidone No 80 mg daily $1336

Olanzapine Yes 10 mg daily $596

Paliperidone Yes 6 mg daily $916

Quetiapine Yes 400 mg BID $1195

Risperidone Yes 4 mg daily $456

Ziprasidone Yes 60 mg BID $645

Antipsychotic Pharmacotherapy

Nicole Romstadt, PharmD

Psychiatric Clinical Pharmacy Specialist
Assistant Professor of Pharmacy Practice
Bernard J. Dunn School of Pharmacy